A n 8-month-old male infant presented to his pediatrician with a 12-hour history of fever, irritability, decreased oral intake, and symptoms consistent with an upper respiratory tract infection. The child had a temperature of 38.8°C rectally and was tachycardic, with a heart rate of 160 beats per minute. The patient's physical examination was remarkable for mild neck tenderness and rigidity and right-sided enlarged cervical nodes. The tympanic membranes were dull and erythematous bilaterally. The oropharynx was full, with erythema of the right posterior pharyngeal wall. The patient's white blood cell count was 20×109/L with a left shift. A lateral neck roentgenogram (Fig 1) was obtained followed by a computed tomographic scan of the neck (Fig 2).

The patient was admitted to the hospital and treatment was started with cefuroxime axetil (100 mg/kg per day). He subsequently developed stridor and progressive respiratory distress requiring emergent intubation. On examination in